Journal of Neurology, Neurosurgery, and Psychiatry 1986;49:451-454

Short report

Pantomime agnosia
LESLIE J GONZALEZ ROTHI, LINDA MACK, KENNETH M HEILMAN
From the Veterans Administration Medical Center and Department of Neurology, College of Medicine,
University of Florida, Gainesville, Florida, USA

SUMMARY Visual agnosia is impaired visual recognition not explained by defective visual acuity,
visual fields, visual attention, or general mental ability. Two nonapraxic patients with lesions in the
left occipital lobe could imitate pantomimes they could not recognise. Although both patients had
a hemianopia, sparing of gesture imitation shows that no visual defect accounts for their inability
to recognise pantomimes. Both patients were amnestic and alexic but had no general impairment of
cognitive ability to account for a pantomime-recognition disorder. These patients seem to have
agnosia for pantomime. From the computed tomograms from these patients, we propose that
inferior visual association cortex is critical for gesture comprehension, whereas superior portions of
these structures are critical for imitating or performing pantomime to an object presented visually.
Liepmann and Maas' suggested that the left hemisphere contains movement formulae that bilaterally
program selection, timing, and spatial relationships
of skilled motor movements. Heilman2 suggested that
these engrams are stored in the inferior left parietal
lobe. Conceivably, brain lesions may destroy these engrams, spare but disconnect them from primary
sensory/sensory association areas, or disconnect them
from primary motor/motor association areas. Based
on this schema a variety of behavioural abnormalities
may be predicted reflecting impairment of different
components of the gestural function system.
Our research group3 proposed that the movement
formulae programs skilled motor movements in much
the same way as Wernicke's area programs linguistic
acts. These movement formulae not only mediate
skilled motor movement but also have a role in discriminating features of gestural movements that are
distinctive and therefore crucial to gestural reception
and production. As in aphasia caused by destruction
of Wernicke's area, input processing as well as production could be disrupted by destruction of the
movement formulae. In contrast, patients whose
movement formulae engrams are preserved but dis-

connected from motor areas, although apraxic, could
perform a gestural discrimination task to differentiate
between well-performed and poorly performed motor
acts. Our findings from studying gesture discrimination in patients with discrete cerebral lesions
confirm that the inferior parietal lobule is crucial for
discriminating and comprehending motor acts.3
Dejerine postulated that the angular gyrus contained a centre critical for comprehending
visual/verbal material4 and described a man who
could write but not read.5 He postulated that damage
to visual areas or visual pathways or both could disconnect the angular gyrus from visual input. The intact angular gyrus would allow the patient to write,
but because the visual areas were disconnected from
the angular gyrus, the patient could not read. Lesions
that induce alexia without agraphia are usually in
posterior portions of the left hemisphere, including
inferior aspects of the left occipital and temporal lobe,
splenium of the corpus callosum or forceps major.6
More anterior and deep lesions may disconnect both
right and left visual areas from language areas.7 Similar lesions may disconnect visual areas from the
movement formulae also stored in the inferior parietal lobe of the left hemisphere. A visuomotor disAddress for reprint requests: Leslie J Gonzalez Rothi, PhD, Audiolsociation may induce visuomotor apraxia in which
ogy and Speech Pathology Service (126), Veterans Administration
cannot pantomime the use of objects they see
patients
Medical Center, Gainesville, Florida 32602, USA.
or imitate pantomimes (but can perform to command), or may induce agnosia of pantomime, or
Received 29 January 1985 and in revised form 28 July 1985.
Accepted 3 August 1985
both. We examined two patients who had alexia with451

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Rothi, Mack, Heilman

Fig CT scan. Topfour views arefrom patient I and bottom four arefrom patient 2.

out agraphia from posterior left hemisphere lesions,
to learn whether they would show visuomotor
apraxia or agnosia for pantomime.
Methods
Subjects
Patient 1, a 65-year-old right-handed man, 38 years before
this admission, had an intracranial haemorrhage probably
secondary to left occipital and posterior temporal arteriovenous malformation (AVM). We admitted him for evaluation of increasingly severe headaches accompanied by
blurred vision. CT without contrast (fig) disclosed an abnormal region consistent with AVM in the left occipital region
immediately posterior to the occipital horn of the left lateral
ventricle. The patient was cooperative and oriented. Digit
span was seven forward and three backward. He could not
recall any of three objects after being distracted for 5
minutes. He had no colour anomia, right-left confusion,
finger agnosia, acalculia, apraxia, neglect, astereognosis, or

agraphaesthesia.
The clinical impression of normal language function was
confirmed by his performance on the Western Aphasia Battery (WAB).8 The patient had a profound defect preventing
his appreciation of complex visual arrays, but he could
match simple stimuli. Appreciation of line drawings was
much worse than that of 3-dimensional objects; objectnaming to palpation was normal. He also had alexia without
agraphia, with reading responses characteristic of spelling
dyslexia. Neurologic evaluation showed a right homonymous hemianopia with corrected vision of 20/40 and
20/200. Mild weakness and clumsiness on the right was
noted.
Patient 2, a 68-year-old right-handed man, was admitted to

the hospital because of increasing irritability and emotional
lability. Six years earlier he had an intracerebral haemorrhage and underwent emergency posterior temporal craniotomy with evacuation of a large intracerebral and
intraventricular haematoma. Postoperatively, he had mild
fluent aphasia with "decreased auditory comprehension, and
occasional jargon," as well as alexia with agraphia. All
deficits resolved quickly and completely except for
significant alexia and a confrontation naming disorder. CT
at 3 and 6 years after onset disclosed "ventricular asymmetry
with dilatation of the left lateral ventricle mainly in the trigone and occipital polar areas." Encephalomacia was noted
in the watershed area between the left middle and posterior
cerebral arteries (fig).
He was cooperative and appropriate throughout testing
and was awake, alert, and oriented to person, place, and
time. He could name only one of four recent Presidents and
after 5 minutes could remember only one of three objects.
Digit span was seven forward and four backward. No
difficulties were noted in calculations, right/left orientation,
colour naming, stereognosis, graphaesthesia, mapping, constructions, or finger gnosis; nor was any neglect noted. Language during spontaneous conversations, as well as formal
testing (WAB8), was normal except for confrontation naming. Performance on the Boston Naming Test9 was severely
impaired (+ 15 of 60 possible). Of his error responses 60%
indicated that he recognised the picture ("takes you one
flight" for escalator). At no time did his performance improve with semantic cueing, but phonemic cueing increased
accuracy 47% of the time. It was evident that the disturbance was anomia rather that agnosia. The patient had
right homonymous hemianopia and moderate-to-severe bilateral sensory/neural hearing loss. The remainder of his
findings were-normal.

Pantomime agnosia

453

Table
Tasks

Correct responses (%)

Control subjects

Patient No

1 Pantomime to verbal command
2 Pantomime function of shown picture
3 Gesture imitation
4 Name gesture performed by examiner
5 Gesture discrimination
6 Gesture discrimination
7 Gesture comprehension

1

2

93*
0
87
63
68
63
50

80*
100
92
63
58
69
70

100
100
100
6
100
90
98

*These scores are within the nonapraxic range for normative data reported previously.10

Special testing
Both patients received special tests of ability to process gestural information presented visually. These tasks were also
presented to 36 men (ages, 40 to 80 years; mean, 60 years)
with no history of neurological disease. The tasks included
pantomime to verbal command (15 items), pantomime to
picture command (20 items), gesture imitation (74 items),
and gesture naming (30 items). In another task of gestural
discrimination (32 items), the subject was to choose from
among three alternatives which gesture best depicted the use
of a target object. The foils were either movement foils (for
example screwdriver for key) or limb orientation foils (for
example lasso for stirring). The control subjects performed
flawlessly on all tasks except the gesture-naming task in
which the group mean was 95-7% accuracy (table).
During the pantomime to verbal command task, neither
patient displayed ideomotor apraxia or verbal-motor disconnection apraxia with either hand.11 To test for visuomotor disconnection apraxia,'2 we gave the
pantomime-to-picture-command task. Patient 2 performed
flawlessly; patient 1, because of his previously described
difficulty in processing pictures, could not perform a single
pantomime when shown pictures. He did, however, accurately pantomime the use of 14 of 18 objects he was shown
but did not hold.
Both patients imitated gestures reasonably well (task 3).
Additionally, these patients performed normally on
pantomiming-to-verbal-command (task 1). In contrast, they
performed poorly when they were visually presented these
same gestures and were asked to label them (task 4) or discriminate them from visually similar gestures (task 5).
Further testing included paradigms used in previous studies to assess gesture discrimination and comprehension
(table). In the discrimination task,3 they watched a videotape and were to choose among three acts which one best
depicted a particular target gesture. In 16 trials the foils were
clumsily produced aberrations of the target act. In the second video study'0 they were presented 20 trials of an actress
performing pantomimes and were to indicate the act being
performed. In both these video tasks the patients performed
significantly lower than the lowest normal.

Discussion
These two nonapraxic patients with lesions in the

dominant occipital lobe had difficulty in understanding pantomimes. Visual agnosia has been
defined as impaired visual recognition not explained
by a defect in visual acuity, visual fields, visual attention, or general mental ability. Both patients could
imitate pantomimes they could not recognise. Therefore, although they both had hemianopia, this or
other visual defects could not account for their inability to recognise pantomimes. Although the patients
were amnestic and alexic, they did not have a general
impairment of mental ability that could account for
this defect. Additionally, because this defect was
present not only in gesture naming but also when the
response involved only discrimination among gestural alternatives, anomia could not be the mechanism. Agnosia for gesture (pantomimes) therefore
seems to be the disorder.
One patient had difficulty recognising pictures of
objects (suggesting a partial agnosia), but could recognise actual objects; the other patient, although anomic, appeared free of agnosia. Therefore, although
visual agnosia may coexist with a gestural agnosia,
they seem to be dissociable phenomena.
Finkelnburg"3 and Head'4 attributed impaired
gesture and pantomime recognition to a generalised
symbolic defect, asymbolia. Duffy and Pearson'5
noted that inability to recognise pantomime was often
associated with aphasia and correlated with naming
ability, aural comprehension, and general linguistic
competence. Like Finkelnburg'3 and Head,'4 Duffy
and Pearson'5 also attributed inability to recognise
pantomime to an impaired central symbolic activity.
Although one of our patients had anomic aphasia, the
other was not aphasic, which indicates that their inability to recognise pantomime could not be attributed to asymbolia in general or again to anomia
particularly. In additon, Heilman et a13 and Varney'6
described patients who had severe language disorders
but could recognise pantomimes. Thus, although
aphasia and impaired pantomime recognition may
correlate, these phenomena are dissociable.

454

Varney'7 studied aphasic patients and noted that
disorders of pantomime recognition always occurred
with reading defects (alexia) but that reading defects
were not always associated with disordered pantomime recognition. Lesions of the dominant inferior
parietal lobe, like those of the occipital lobe reported
here, induce not only alexia,4518 but also defective
comprehension of pantomime.3 However, unlike occipital lobe lesions, those in the parietal lobe are associated with production defects such as agraphia and
apraxia. Unfortunately, Varney"7 did not test for
these disorders nor specify the loci of the lesions in his
patients.
DeRenzi et al1 requested 150 patients with left
hemisphere disease to imitate movements and demonstrate the use of visually displayed objects. These patients were also verbally asked to pantomime object
use. DeRenzi et al found seven patients whose performance was worse in the visual than in the verbal
modality. Although we first suspected that our patients would have difficulty performing pantomimes
to visually presented objects and have difficulty imitating gestures, they performed these tasks well. The
lesions in our patients involved the inferior portions
of the visual association areas (that is Brodmann
areas 18, 19, 37). Unfortunately, DeRenzi et al did
not test for gesture comprehension and did not describe the anatomical lesions in their patients with visuomotor disconnection apraxia. The inferior visual
association cortex is critical for gesture comprehension, but the superior portions of visual association
cortex (Brodmann areas 18, 19) may be critical for
imitating a pantomime or performing a pantomime to
a visually presented object.
Although our patients had alexia without agraphia
and an associated disorder of pantomime recognition,
not all patients with alexia and agraphia have a disturbance of pantomime recognition. For example, we
recently examined a patient who had alexia without
agraphia from a left occipital lobe lesion; his performance on the discrimination and comprehension
tasks was flawless. His lesion also involved the inferior visual association areas (that is, inferior portions
of Brodmann areas 18, 19, 37). We cannot be certain
that minor anatomic differences between lesions in
these patients account for behavioural differences.
However, differences in premorbid brain organisation
may be responsible.
We are grateful to Dr Russell Bauer for information

Rothi, Mack, Heilman

he provided on the visual object agnosia displayed by
patient 1. This work was supported in part by Grant
NS-20204 from the National Institutes of Health. The
study was presented in part at the annual meeting of
the International Neuropsychological Society, San
Diego, California, USA, February, 1985.

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